Key takeaways from this episode

• As of September 17, the House GOP stopgap bill would extend the current budget, and the current Medicare telehealth rules, to November 21. Congress has 13 calendar days to get something through both houses and to the president before the September 30 deadline.
• Extending telehealth is not the controversial part. Both parties appear to accept a continuation of the current rules, and two other bipartisan bills would make telehealth a permanent Medicare benefit.
• The most likely path is a continuation of the current telehealth rules for 2026, with any coding and reporting changes arriving in 2027. The 2026 proposed rule is worded to allow the current regulations to continue, and the permanent-coverage bills would be a small pivot from that language.
• The sticking point is the ACA premium tax credits, not telehealth. Democrats want the credits extended in the stopgap so the November 1 exchange enrollment window opens with the credits in place; Republicans argue there is time before year-end. A failed stopgap means a shutdown and a lapse in telehealth coverage.
• If telehealth coverage lapses, it reverts to pre-COVID rules. Home-based telehealth becomes non-covered for Medicare patients not in a Medicare-approved originating site, so Medicare will not pay and the patient can be asked to pay instead.
• An ABN is recommended but technically not required for a non-covered telehealth visit. Because the service is still covered in a Medicare-approved facility, getting the ABN signed is the safer practice.
• For telehealth visits already scheduled for the first week of October, explain the situation to the patient and offer the option to pay out of pocket. Any disruption in coverage is expected to be short, and patients can also be encouraged to call their congressman.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 258, recorded September 2025, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

Telehealth watch: where things stand on September 17

[00:00] Scott Painter: On this episode: telehealth, where we are right now. Welcome to episode 258 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. We wanted to have Mark update us on what's happening with telehealth. Where are we right now? We're approaching the September 30th deadline and we're seeing some activity. We're recording this podcast on September 17th, so we will give you the most up-to-date information we have and keep an eye out. There's nothing definitive yet, but Mark can share with you the direction it's going. So, Mark, where are we?

[01:00] Mark Painter: Watching and waiting still, but we have at least got some action, and I think we've got at least some guidance. Apparently there was a bipartisan discussion on fixing the budget for a year. They're trying to get a year-long budget deal in place, but there were definitely a few sticking points, and apparently the Republican, the GOP caucus, decided to introduce a stopgap bill. They wanted it to be, as they called it, clean, without any specific areas of concern or disagreement. In that stopgap measure they have an extension of the current budget to November 21st. So essentially they're giving us a little over a month, not quite two months, of a window to keep the government open.

Within that, they have a continuation of the current telehealth rules, which is what we were expecting. The continuation of the telehealth rules is not a controversial issue, apparently, which is a good sign. That's one of the things we've been talking about: telehealth is an important part of healthcare. It fills a lot of holes, some of the biggest holes in Medicare as far as access. As we saw in the proposed rule, the most likely path forward at this point in time is a continuation of the current rules. Now, there are two other bills with some momentum and bipartisan support that would actually set telehealth up permanently as a covered benefit within Medicare.

The proposed rule as it is set up is really designed, or worded, in a way that would allow for a continuation of the current regulations moving forward, and it would be a small pivot from some of the telehealth language in those telehealth bills. So it's likely, I'm going to say, that telehealth is going to be covered under a continuation for 2026, with any potential changes in coding and reporting requirements going into play in 2027 if some of those other bills come through. But we'll have to watch to see if any of those other bills come through in the discussions they're having with the budget, which seems to be taking all of the attention of Congress right now, or the majority of it.

The ACA tax credit fight and the risk of a shutdown

Now we do have some pushback, unfortunately, on the stopgap measure, and that is actually also part of the healthcare issue. The Democrats do not want to see the ACA tax credits, the benefits, expire when this particular budget goes into play. There is no action within the stopgap bill that prevents the expiration of those. The Republican argument is, we are just continuing the current state until November 21, so there's still time before the end of the year to extend the ACA credits. A number of states have filed a petition to ask for the ACA credits to be extended. There does seem to be some bilateral support to extend those ACA credits, especially in rural areas, where there are a number of gaps in coverage other than under the health exchange ACA programs.

The argument that's going forward is: number one, if they let it expire on September 30th or October 1st, and then take up the argument again for the full budget and add it back in, they've missed the beginning of the update window. As you know, the enrollment period starts on November 1st for patients to sign up for the healthcare exchange. If they passed the stopgap, those credits would not be available at the beginning of the enrollment period, which, the argument goes, would put a number of individuals in a position where they couldn't afford to sign up for an ACA program. So the Democrats would like to see that extended in the stopgap measure, or at least through 2026, so that the November 1st enrollment period opens with appropriate pricing with the ACA credits. We'll have to see how the argument goes.

The Democrats right now are taking a fairly hard line, saying without that ACA credit we are not voting for the bill or the stopgap measure. So the Republicans would have to line up every Republican; they could only afford to lose a couple of folks from their caucus to actually push this through both the House and the Senate. At that point in time, according to what I'm reading, the bipartisan discussions around a full budget would continue to try to pass a full-year budget before the November 21 deadline that the stopgap measure would put in place.

So we're still watching. There's nothing really set in stone right now, but again, I would have to say I'm encouraged that everybody seems to feel that telehealth, and the extension of telehealth rules under the current rules, is acceptable. We're going to have to watch to see if there's a gap in coverage. If there is a shutdown of the government, then we would also have a shutdown of the telehealth rules, unless Congress decided to open up telehealth separate from the budget, which doesn't seem like a likely pathway, as everybody's trying to hold the packages together and keep the budget as the stick to actually make a final decision. So whether or not they get through on time, we've got 13 calendar days for Congress to get something through both houses and to the president so we don't have a disruption in coverage as well as a shutdown of the government.

Should you keep October telehealth visits on the books?

Scott: Ray, questions, comments? No? All right. I have one question based on what you said. If patients are scheduled for telehealth beginning in October, are you saying that you'd be fairly comfortable keeping those patients on the books for telehealth appointments, based on where everything's moving, but being able to pivot at the last minute if there was some adverse action for telehealth?

[09:00] Mark: I don't know that I said that, because I don't have a ton of faith that this is all going to come through with the stopgap measure. I do think it's a possibility. The other thing that I'm really banking on at this point in time is that if there is a disruption in coverage, it'll be fairly short. I do think that, unfortunately, with the tie of everything to the budget, this seems to be the only way Congress gets anything done, by burying or tying things together. I guess you could put this as part of the democratic system: everybody wants something, and if everybody gets something, then you can live with not getting everything. So that's maybe where the argument really comes down.

If the Democrats are successful in blocking the stopgap measure, or successful in convincing the Republicans to extend the ACA credits in the stopgap measure, then we probably won't get a disruption. And that all has to happen in the next 13 days. Or, the last one is, if the Republicans are successful holding everything together and they push the stopgap through, we won't have a disruption. But now we have another looming deadline, which is November 21. So they've just kicked it down the road.

What happens to telehealth coverage if it lapses

Scott: You have a question, Ray?

Dr. Ray Painter: Yeah, I did think of a question. With all that's happened with telehealth, and what's been covered and not covered, if they did not cover it and it lapsed, is it going back to an uncovered service?

[11:00] Mark: It would revert to pre-COVID guidelines. That would mean non-covered for those patients that are not in a Medicare-approved facility. Our issue prior was that Medicare did not cover telehealth in the home setting, and then when Medicare did cover it, it became a reimbursable event that Medicare paid for. With it being non-covered, essentially Medicare is not going to pay for it, but you could have the patients pay for it. Because it is covered in a Medicare-approved facility, it's always a good idea to get an ABN. An ABN is recommended, but technically not required, because it's a non-covered service.

Scott: All right, so given all that you heard, Ray, let's do a hypothetical. If you were practicing today, what would you do with your telehealth patients that are scheduled for the first week of October?

Ray: I'd probably explain the situation to them, blame it all on the government, and ask them if they want to go ahead and pay for it if the feds didn't.

[12:00] Mark: I would also add: have them call their congressman.

Sponsor, seminar dates and final thoughts

[13:00] Scott: Yeah, for sure. Put some pressure on. All right, well, that's our telehealth watch update. Let's wind this episode up here. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, you can go to modmed.com/prs for specials for our listening audience.

We also want to let you know that the Urology Advanced Coding and Reimbursement Seminar is coming up very soon, in December in Las Vegas and at the end of January in New Orleans. With all the new codes, new rules, new denials, new pharmaceuticals, new audits and the new technology coming in, that's what we'll be talking about. There's a lot happening in urology and a lot going on, and it's hard to digest in bits and pieces, so we encourage you all to come down and join us in Las Vegas or in New Orleans. You can go to the episode page, which is prsnetwork.com/258, for links to register, or you can go to prsnetwork.com and click on seminar registration. We'd love to see you there. All right, let's get some final thoughts. Mark, final thoughts.

[14:00] Mark: I'd love to say that we've changed our position on all this stuff. We haven't, totally. Again, I am encouraged by the underlying sentiment that telehealth is a part of Medicare and should remain so. Obviously I'm still not encouraged by the lack of agreement and the lack of an official action that gives us a path forward for at least another year, if not longer. So we'll have to keep an eye on it. We'll keep reporting on it, and we wish them all luck to get something in.

Scott: Ray, final thoughts.

Ray: First, I'd like to apologize for misspeaking. I said blame it on the feds; I meant blame it on politics. This is strictly a political football that nobody wants to pick up and run with, because from what we hear, everybody is in favor of continuing it. Why don't they fix it?

Scott: So true. All right, that's all we have for today. Thank you all for listening. Take us out, Ray.

Ray: Happy coding.

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